Academy Sees Health Equity Boost in Proposed HHS Rule

AAFP Supports Expanding Enrollment, Replacing Waiver Guardrail

August 5, 2021, 8:40 a.m. News Staff — The Academy last month welcomed HHS rulemaking that would roll back regulations undermining comprehensive, affordable health coverage while increasing opportunities for some low-income patients to enroll in plans under the Patient Protection and Affordable Care Act.

Exchange Direct Enrollment

HHS’ Exchange Direct Enrollment option, finalized under the previous administration, allows states to opt out of using a single, centralized exchange (for most states, HealthCare.gov) when connecting individuals with insurers, in favor of private-sector entities. The AAFP last year laid out several objections to that rule, chiefly the concern that it would increase the number of uninsured patients, erode affordable access to primary care and worsen health outcomes.

“The AAFP supports the proposal to repeal the EDE option and corresponding user fee and urges HHS to finalize it,” the letter said, pointing out that “the COVID-19 special enrollment period has again demonstrated the value of the exchange, with more than 1 million consumers enrolling in a qualified health plan.

“Maintaining a central portal for enrollment is needed to reduce the burden on consumers, avoid confusion or deceptive marketing practices and ensure seamless enrollment for individuals eligible for Medicaid and the Children’s Health Insurance

Program, and promote affordable access to comprehensive coverage.”

Section 1332 Waivers

In the proposed rule, HHS outlines a new interpretation of guardrails for Section 1332 waivers — one the Academy favors.

The waivers allow states to set aside certain parts of the ACA in pursuit of “innovative strategies” to increase comprehensive health coverage. In 2018, HHS broadened its criteria for approving Section 1332 applications, a move the Academy strongly opposed.  

“We support the proposal to rescind and remove any references to the 2018 guidance,” the Academy wrote.

Under the new rule, HHS would revert to 2015 guidance for Section 1332 waivers, directing that waiver recipients provide coverage that is at least as comprehensive as that offered through the ACA’s exchange and free of excessive out-of-pocket costs. “This proposal is consistent with AAFP policy for ensuring equitable access to comprehensive, affordable health coverage, and we urge HHS to finalize it,” the letter said.

ACA Enrollment and Medicaid Coverage

The proposed rule would extend the ACA’s annual open enrollment period by one month, starting with the 2022 plan year. Allowing individuals to find insurance from Nov. 1 to Jan. 15 (rather than Dec. 15) “would benefit consumers who qualify for marketplace subsidies and are auto-enrolled into coverage, as it would allow them the chance to change plans in the event their subsidy is reduced,” the Academy wrote.

HHS’ return to assisting consumers via marketplace navigators, the letter added, would answer a well-documented need.

“A 2020 national survey found that consumers highly value enrollment assistance, and 40% of those who enrolled in coverage with help said it was unlikely they would have coverage if not for consumer assistance,” the Academy said. “Navigators are well equipped to help enrollees understand the basic concepts of health coverage, including the primary and preventive care they can receive without cost-sharing and how to find an in-network primary care physician.”

The Academy also expressed support for the proposed rule’s cementing of a monthly SEP for certain low-income individuals, a move in line with the AAFP’s “health care for all” policy. The SEPs “would increase enrollment opportunities for low-income individuals and ultimately enable them to receive essential primary and preventive care,” the letter said, and would be of particular importance to those at risk of losing Medicaid coverage after the COVID-19 public health emergency ends. “Ensuring continuous coverage will be particularly vital for individuals with chronic conditions and the growing population of patients experiencing post-COVID conditions.”

The proposed rule noted that the new SEP could help postpartum patients who lose Medicaid coverage just six weeks after the end of pregnancy. Better still, the Academy wrote, HHS should extend Medicaid coverage to at least one year after the end of pregnancy to ensure access to continuous postpartum care and address high U.S. maternal mortality, as the AAFP has long advocated.

“For many patients, even seamlessly transferring from Medicaid to marketplace coverage could require them to change physicians due to varying provider networks, which would disrupt physicians’ ability to monitor various conditions and the patient-physician relationship,” the letter said. Such disruptions, the Academy warned, “contribute to the high rates of maternal mortality among the Medicaid-eligible population.”

The Academy also expressed concern that postpartum patients may forgo necessary care due to cost if they transfer from Medicaid to a marketplace plan. Instead, the Academy called on HHS to issue guidance to states on their option to extend postpartum Medicaid coverage from 60 days to one year, as established by the American Rescue Plan Act. (The Academy made a similar appeal to CMS earlier in July.)

Additionally, the Academy voiced approval of the proposed rule’s change to previously finalized regulations requiring insurers to bill separately for some reproductive health services, increasing burdens on both patients and clinicians. Reverting to prior policy would restore compliance flexibility to insurers and allow ACA enrollees to pay for all types of coverage in a single transaction, in line with AAFP advocacy efforts.